1. Field of the Invention
The present invention relates generally to electronic generation and retention of clinical and administrative medical records; and, more particularly, to a system for populating patient records by use of evidence-based evaluation systems, which compare the medical practitioners diagnoses to predetermined objective and subjective responses, including those of experts in the field, to produce accurate patient chart notes and the integration of stored and generated data into clinical and administrative medical record keeping and billing.
2. Description of Related Art
Modern medical practices demand accurate medical records of patient history and treatment. The information maintained in a patient history and treatment record is what the physician relies on to carry out a course of treatment, and also to justify the billing for service.
Thus, medical records exist primarily for the use of health care providers to record the information related to the continuing care of each patient. These records are generally created in two ways. 1.) By historical data entry, usually subjective in nature, of a patient's past medical history and health related issues and experiences; and, 2.) by physicians and medical experts after various episodic encounters with a patient including objective observations, clinical tests, and subjective symptom gathering from the patient concurrent with the episode. Usually, as the patient experiences further and differing treatment, these records follow the patient from physician to physician. The medical record is episodically updated. From this diverse data the physician makes a diagnosis and prescribes a course or regimen of treatment. The increasing demands placed on a physician's time, however, results, too often, in patient charts and records that are improperly maintained and difficult, at best, to read.
Paper medical records have been used for many years and remain the standard way of doing things, even today. A patient's medical record is not a single file, but a multitude of records that are retained amongst many different providers, hospitals, clinics, and schools. These paper records have numerous obvious limitations and drawbacks, including a lack of legibility and inconsistency of format. Notes are often illegible, paper suffers from wear and can only be in use at one location at a time, thus making it unavailable to more than one practitioner at a time. Further, paper records require large secured (HIPPA) storage spaces as well as numerous shelves or cabinets. A staff of trained personnel must be maintained to manually file, retrieve and keep track of the records. Loss, damage, or destruction of the records can occur due to numerous mishaps such as flood, fire or even a spilled beverage. Backup of paper records is difficult, time consuming, expensive and many times not current.
Thus, many record keeping systems have become at least partially electronic to alleviate the above problems. While software programs exist to help individually manage the above areas, none of them are compatible so that one software program will manage an entire medical office. When creating patient history (personal information and medical/surgical history), for example, patients generally fill out personal and medical history information forms. This information is then entered manually into the patient file and record by office staff into the office computer system. This is a slow, time consuming, labor intensive process for the office staff/employees.
In order to bill a client, a physician has traditionally completed a superbill/patient encounter form after a patient's visit. This superbill has the diagnosis. This (ICD) code and the procedure, (CPT code) which describe the surgery or E&M code details of the encounter is required for billing the patient or insurance company. The office staff then fills out the insurance claim form (the HCFA 1500 form) manually for billing the insurance company, or the information and codes are entered manually by the office staff into a computer software system which then creates a patient file. The office staff then can enter the appropriate billing codes into the insurance claim form (HCFA 1500) which is part of the computer system. This can then either be printed out and mailed to the insurance company or sent electronically to the insurance company.
Even with the advent of automation, dictation remains the primary means of documenting patient care. The process requires a physician dictate the patient name, ID, age, and other demographic information, followed by the description of the patient complaints, the observations from the exam, the diagnosis, and description of treatments. This procedure has to be repeated for each patient encounter to assure accuracy. Because of the relationship of symptoms to diagnosis, this entails dictating repetitive medical information. Most dictation is hand transcribed into paper format for the file. Solutions have been applied to improve the dictation efficiency by using automatic speech recognition (ASR) and super macros that allow a physician to use a single phrase to describe a medical condition or treatment. ASR has to date been a disappointment due to its accuracy problems.
Many software programs exist for assisting the practitioner with billing. However, the input is still mostly manual. This process is very time consuming and labor intensive for office staff and expensive to the physician to pay for the man-hours and labor to perform the tasks required for billing. Further, little of this billing software is compatible with the software for maintaining medical records. Thus, one cannot easily import information from the medical records software to existing billing software. In addition, there are inventory and recording problems.
To add to the complexity, when a physician deems necessary, various supplies are dispensed to a patient. Some of the supplies that may be dispensed on any given office visit include, but is not limited to, splints, casts, fracture orthoses, pads bandage and dressings, orthotic devices, and braces. Currently these items etc. are dispensed/given to a patient with virtually no communication to office staff/billing employees other than recording these on a superbill, which frequently can result in missed billing for the supply and failure by the office to reorder and restock the utilized supplies.
Frequently, patients will require prescription medication from a physician for appropriate treatment of a medical problem. Currently, these are hand written on a paper prescription forms by the doctor and given to the patient to take to a pharmacy to be filled and dispensed. This method is slow and labor intensive. Also, errors can occur at the pharmacy due to inability of the pharmacist to read the handwriting of the physician resulting in medication and dosing errors for patients. Additionally, some patients lose the paper prescription and consequently never obtain necessary medication.
With the ever increasing cost of healthcare, surgeries, medications etc., it has become necessary to find means to justify cost and efficacy of medical treatments. Until now, very little can be done to identify and justify costs and efficacy of treatments. Random studies can be done in teaching hospital settings for studies on procedures. Attempts have been made to retrieve data from multiple physician offices to try to study effectiveness of various treatments and procedures. Therefore, a need exists to provide an integrated system and method for documenting and billing patient medical treatment.
Some offices have adopted Electronic Medical Records (EMR) to replace paper. These systems, although gaining acceptance in the medical profession, suffer serious limitations. Some, which are in use, involve electronic records and templates. One type involves pre-created documents that contain specific areas that are quasi-customizable for documenting specific patient information. Primary use of these templates is in administrative record keeping, such as super bills for insurance interface and the like.
Further, to facilitate use of EMR, systems have been created to aid in the process of creating these medical records. Most of the current applications, however, are designed to follow the existing paradigm used for generating a patient chart note.
These applications use a spread sheet that corresponds to a practice superbill to allow the physician to check off boxes that correspond to the treatment administered. Edit fields are available where the physician can type in information related to the specifics of the symptoms observed or to the treatment administered. While useful for gathering and storing information into a database for future retrieval, such systems are cumbersome to use and require a physician to be tied to a computer. Because this is not possible during the patient exam or treatment, the physician is still left to rely on hand written or dictated notes that are subsequently entered into the spread sheet. This has the obvious flaws of causing the possibility of inaccurate information and loss of efficiency of the physician's time, as well as, double entry.
Many medical applications software allow the practitioner to slightly modify the template information or, in some cases, create the template prior to use. In either case, population of the template involves dictation or keystroke application of information created by the practitioner. The ability to customize is often more of a hindrance to the product's adoption due to the additional burden placed on the practitioner, the emphasis having been wrongly placed on the ability to adjust the document wording as opposed to its content. While templates have the advantage of allowing for rapid chart generation, they are limited by capturing only that information generated by the practitioner to populate the template. In addition, once the template content is modified, the interactions with other aspects of EMR are modified or destroyed requiring complete alteration of the system.
Still, other systems have been designed to guide the physician through the diagnosis and treatment process. The applications queries the physician for information, makes suggestions for treatments and documents the choices and information typed in. These systems are particularly cumbersome to use, since a physician having been trained in the field of medical practice, already knows the diagnosis and treatments.
In an effort to reduce inconsistency of format the Problem Oriented Medical Record (POMR) was introduced in the 1960s by L. L. Weed. This system relies on the acronym SOAP as a standard approach to recording entries. The four parts of this acronym are expressed as follows:
Subjective—this summarizes the patient's statement of his or her concerns, history and the story of what has transpired. It includes the chief complaint or concern.
Objective—the practitioner's observations, and results of physical evaluation.
Assessment—the practitioner's opinion of diagnosis based on the subjective and objective findings.
Plan—a course of treatment or plan on what the practitioner intends to do next and instructions to the patient as to treatment and further evaluation or testing.
It is well documented within the medical profession that a specific set of symptoms, whether objective or subjective, correlates to a particular diagnosis. The problem is that the number of symptoms required to uniquely identify a particular condition and, therefore, a course of treatment, is large. Only by use of electronic data handling and information flow path analysis is a usable correlation between the two achievable.
One of the emerging techniques in patient episodic diagnosis is the use of evidence-based practice guide-lines. A problem with this technique is that professional practitioners are faced with additional data, which relates to their profession and impacts their continued ability to manage professional scenarios. Thus, these professionals, whose job it is to keep up with the latest techniques and information for problems solving, find themselves in a further information overload. This situation translates into disconcertingly low rates of compliance with widely disseminated evidence-based treatment guidelines even by very knowledgeable practitioners.
Awareness may not be the only explanation for the modest implementation rate of evidence-based “practice guidelines.” The failure to use factually based scenarios and evidence-based diagnosis, revolves around the inability of the practitioner to find time to read and digest the overwhelming volume of data, which relates to their profession and impacts their continued ability to manage evidence-based professional scenarios. Thus, medical professionals find themselves in an information dilemma in an attempt to keep up with the latest techniques and information required for diagnosing based upon evidence-based practice guidelines.
Furthermore, with the passage of HIPPA regulations, EMR systems must meet very rigid security standards. Having large databases of patient related medical information, without appropriate safeguards is risky. Therefore, a requisite of any large relational database, which stores sensitive and complete medical related information associated with a particular patient, must be secure.
Finally, none of the current medical information systems make any attempt to pool the treatment data that is produced every day into a database that is easily accessible and relational to allow for outcome studies. Outcome studies have become increasingly desired and demanded by insurance companies to justify payments for patient care. Physicians would also gain empowerment to validate their practice of medicine. Currently, the National Institute of Health (NIH) is attempting to pool various databases created for specific studies into a single database. This plan still fails to address the vast amounts of data produced by private practitioners.
It would, therefore, be desirable to have an easy-to-use, accurate, secure system to facilitate the recording of patient treatment information in such a manner as to produce a chart note record, and produce billing data as well as raw treatment data useful for outcome studies. It would also be desirable that the system be minimally intrusive to a physician's manner of work thereby allowing the physician to maximize time spent with patients. For maximum efficiency, such a system should also provide means by which personnel, other than the physician, can interface with the data base to quickly schedule patients, enter demographic information, and allow patients to directly enter their medical history either through a kiosk or through an electronic interchange such as smart cards. Further, it would be advantageous to have a system, which is computer based, that would self generate much of the information now entered by the physician and cascade this generated information to populate an integrated administrative and medical record system.